WILLIAM M. ISBELL, MD Jeremy R. Stinson PA-C

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1 WILLIAM M. ISBELL, MD Jeremy R. Stinson PA-C Post-Operative Rehabilitation Guidelines for Total Shoulder Arthroplasty (TSA) The intent of this protocol is to provide the physical therapist with a guideline/treatment protocol for the post-operative rehabilitation management for patients who have undergone a total shoulder arthroplasty. It is by no means intended to be a substitute for a physical therapist s clinical decision making regarding the progression of a patient s post-operative rehabilitation based on the individual patient s physical exam /findings, progress, and/or the presence of postoperative complications. If the physical therapist requires assistance in the progression of a postop patient who has had a TSA, the therapist should consult with Dr. Isbell. Note: Time frames given are only an estimated guideline and all patients should be progressed based on meeting clinical criteria. Patients with a TSA secondary to fracture or with a concomitant rotator cuff repair could likely be delayed from guidelines Passive Range of Motion (PROM): PROM for patients who undergo TSA is defined as ROM that is provided by an external source (therapist, instructed family member, or other qualified personnel) with the intent to gain ROM without placing undue stress on either soft tissue structures and/or the surgical repair. PROM is not stretching!!! The scapular plane is defined as the shoulder positioned in 30 degrees of abduction and forward flexion with neutral rotation. ROM performed in the scapular plane should enable appropriate shoulder joint alignment. Progression to the next phase based on Clinical Criteria and Time Frames as Appropriate. Phase I- Immediate Post Surgical Phase (Day 1-6 weeks): - Patient s family independent with o Joint Protection o PROM o Assisting with taking on and off sling and shirt o Assisting with prescribed home exercise program - Promote healing of soft tissues. - Maintain integrity of replaced joint.

2 - Gradually increase PROM of the shoulder. - Restore active ROM of the elbow, wrist and hand. - Patient independent with the use of conservative measures of pain control: o Appropriate posture/positioning o Use of cryotherapy o Deep breathing/relaxation - Reduce muscular inhibition - Independent with ADL s with modifications and compensations to maintain the integrity of the replaced joint. - Sling is worn for 3-4 weeks post-operatively except during physical therapy and home exercises. Sling is worn when sleeping and weaned after the fourth week. The use of a sling may be extended for a total of six weeks, often in a revision setting. - While lying supine, the distal humerus/elbow should be supported by a pillow or towel roll. Avoid shoulder hyperextension /anterior capsule stretch/subscapularis stretch. Patients should be advised to always see their elbow while lying supine. - No shoulder AROM. - No lifting of objects with operative extremity. - No stretching or sudden movements (particularly external rotation). - No supporting of body weight by hand on involved side. - Keep incision clean and dry (no soaking/wetting for 2 weeks); No whirlpool, Jacuzzi, ocean/lake wading for at least 4 weeks. DAY ONE TO TWENTY-ONE: Acute care therapy (Day one to four): - Most patients s/p TSA will begin the below PROM program post operative day #1; however, shoulder PROM for any patients having a revision and/or having poor bone stock will be based on the surgeon s assessment of the integrity of the surgical repair. It is common for the start of PROM of the shoulder to be delayed up to 4 weeks post-op in these cases. - Begin PROM in supine after complete resolution of interscalene block. o Forward flexion in supine to tolerance (not to exceed 90 degrees.) o Elevation in the scapular plane in supine to tolerance (not to exceed 90 degrees). No pure abduction ROM. o External rotation (ER) in scapular plane to 30. (It is vital that PROM does not induce stress on the anterior joint capsule/subscapularis.) o Internal Rotation passively to chest o Active/Active assisted ROM (A/AAROM) of elbow, wrist, and hand. - Begin periscapular sub-maximal pain-free isometrics in the scapular plane. - Continuous cryotherapy for first 72 hours post-op, the frequent application (4-5 times a day for about 20 minutes). - Patient education regarding proper positioning, posture cues, and dislocation precautions. Post Acute Care Program (Day five to twenty-one) - Continue PROM as above - Educate patient with appropriate progression of A/AAROM of elbow, wrist and hand. - Continue periscapular sub-maximal pain-free isometrics. - Begin sub-maximal pain-free deltoid isometrics in scapular plane. - Frequent cryotherapy (4-5 times a day for about 20 min.)

3 - Patient education as above. - Pendulum exercises - Cervical AROM program with emphasis on cervical thoracic neutral positioning as needed. 3WEEKS TO 6 WEEKS: - Continue PROM: o Forward flexion in supine to tolerance (Not to exceed 120 degrees). o PROM elevation in the scapular plane in supine to tolerance (Not to exceed 120 degrees). o ER in scapular plane to tolerance, respecting soft tissue constraints, typically degrees at this point. - AROM progressed to gentle resisted exercise of elbow, wrist, and hand to tolerance. - Progress periscapular and deltoid sub-maximal pain-free isometrics. (Avoid shoulder hyperextension when isolating the posterior deltoid.) - Continue frequent cryotherapy. - Continue patient education. - Continue to provide/progress therapeutic exercise/positioning to correct any postural cervical thoracic dysfunction. - Patient should be weaning off of sling after 4 weeks post-op. Criteria for progression to the next phase (Phase II): - Tolerates shoulder PROM and AROM program for elbow, wrist and hand. - PROM should flexion >90 degrees - PROM shoulder scaption >90 degrees - PROM external rotation >45 degrees - PROM internal rotation >70 degrees - Patient demonstrates the ability to isometrically activate all components of the deltoid and periscapular musculature in the scapular plane. Phase II- Active Range of Motion/ Early Strengthening Phase (Week 6-12): - Continue progression of PROM (remember that normal/full PROM will not be expected). - Gradually restore AROM. - Control pain and inflammation. - Allow continued healing of soft tissues. Do not overstress healing tissues. - Re-establish dynamic shoulder stability. - Continue lying supine with a pillow or towel roll placed behind the elbow to avoid shoulder hyperextension. - In the presence of poor shoulder mechanics avoid repetitive shoulder AROM exercises/activity. - Restrict heavy lifting of objects to no heavier than a coffee cup. - No supporting of body weight by hand on involved side. - No sudden jerking motions. WEEK 6 TO WEEK 8: - Continue with PROM program. - Begin shoulder A/AAROM as appropriate.

4 o Forward flexion and elevation in scapular plane in supine with progression to sitting/standing. o ER and IR in the scapular plane in supine with progression to sitting/standing. - Begin gentle glenohumeral IR and ER sub-maximal pain free isometrics in 0 degrees rotation, 30degrees abduction and neutral extension. - Initiate gentle scapulothoracic and glenohumeral rhythmic stabilization in supine as appropriate. - Begin gentle periscapular and deltoid sub-maximal pain free isotonic strengthening exercises, typically toward the end of the 8 th week (Avoid shoulder hyperextension). - Progress strengthening of elbow, wrist and hand with light resistance (2-4 lbs). - Gentle glenohumeral and scapulothoracic joint mobilizations as indicated (Grade I and II). - Continue use of cryotherapy PRN. - Patient may begin to use hand of operative extremity for feeding and light activities of daily living. WEEK 9 TO WEEK 12 - Continue with program as above. - Continue light functional activities. - Begin active supine forward flexion and elevation in the plane of the scapula with light weights (1-3 lbs) at varying degrees of trunk elevation as appropriate (i.e. Supine lawn chair progression with progression to sitting/standing). - Progress to gentle glenohumeral IR and ER isotonic strengthening exercises. (Remember the rotator cuff is absent so minimal isolated IR and ER motor control exists). - Progress periscapular and deltoid isotonic strengthening exercises. (Continue to avoid shoulder hyperextension.) - Progress elbow, wrist and hand exercises with resistance. - Continue gentle glenohumeral and scapulothoracic joint mobilizations as above. - Continue use of cryotherapy PRN. Criteria for progression to the next phase (Phase III): - Tolerates shoulder A/AA/PROM program. - AROM and gentle resistance (2-3 lbs) program for elbow, wrist and hand. - Patient demonstrates the ability to isotonically activate all components of the deltoid and periscapular musculature. - PROM shoulder flexion 140degrees - PROM shoulder scaption 120 degrees - PROM shoulder external rotation 60 degrees in plane of scapula - AROM shoulder elevation >100 degrees against gravity with good scapulohumeral rhythm Phase III- Moderate strengthening (Week 12+) Maintain pain-free appropriate shoulder mechanics. Enhance functional use of operative extremity and advance functional activities. Enhance muscular strength, power, and endurance. No lifting of objects heavier than 6lbs.

5 So sudden lifting or pushing activities. No sudden jerking motions. Avoid exercise and functional activities that put stress on the anterior capsule and surrounding structures. (Example: No combined ER and abduction above 80degrees abduction). WEEK 12 TO WEEK 16: Continue PROM as needed to maintain ROM. Progress AROM/strengthening exercises/activity. Progress to gentle resisted flexion, elevation in standing. Phase IV- Continued Home Program (Typically 4+ months post-op): Typically patient is on a home exercise program at this stage to be performed 3-4 times per week. Progress strengthening program. Return to functional activities. Return to recreational hobbies, gardening, etc within restrictions/limits as identified by progress made during rehabilitation and outlined by surgeon and physical therapist. Criteria for discharge from skilled therapy: Patient able to maintain pain free shoulder AROM demonstrating proper shoulder mechanics. (Typically degrees of elevation with functional ER of about 30 degrees.) Maximized functional use of operative extremity. (Typically able to complete light household and work activities.) Maximized muscular strength, power and endurance.

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